Learning objectives

 Define Multiple pregnancy

 Enlist 2 varieties of Twin pregnancy
 Enlist 4 types of Monozygotic twin according to
chorionicity
 Describe etiopathology of Multiple pregnancy
 Describe clinical features and diagnostic method for
Multiple pregnancy.
 Discuss the principles of antepartum and
intrapartum management of Multiple pregnancy.
 Describe antepartum, intrapartum, postpartum
complications of Multiple pregnancy
 Enumerate fetal complications in Multiple
pregnancy
Definition
 Simultaneous development of more than one fetus
in the uterus
 2 fetuses –twins (commonest)
 Triplets, quadruplets etc
Incidence
 Hellin’s Law – Twin = 1:80
Triplets = 1:80²
Quadruplets =
1:80³
 Monozygotic = 3-5/1000 births
 Dizygotic = varies depending on
maternal age, race and
geographical distribution
Aetiology
 Assisted reproduction techniques
 Increase parity
 Increase maternal age
 Family history
 Previous multiple pregnancy
 African race
Type of multiple pregnancy
1. Dizygotic / binovular / fraternal
2. Monozygotic / Uniovular / identical
Types of Monozygotic twins
1. Dichorionic Diamniotic :
i. Division occurs with in 72 hrs of fertilization
[Link] have 2 diff placentas/ single fused
placenta [Link] to differentiate form
dizygotic twins [Link] babies have same sex

2. Monochorionic Diamniotic:
I. Division occurs with in 4 – 8 days of
fertilization
3. Monochorionic Monoamniotic:
I. Division occurs 9-12 days of fertilization

4. Conjoined twins:
I. Division occurs after 13th day
II. Incomplete division of embryonic disc
III. Types: -thoracopagus
- omphalophagus
-craniopagus
-pyopagus
-ischiopagus
 Diamniotic Diamniotic Monoamniotic
Diamniotic
DiChorionic Monochorionic single Monochorionic
Dichorionic
fused placenta placenta single placenta
Separate placenta
Frequency 27% Frequency 36% Frequency 2%
Frequency: 35%
Mortality 11% Mortality 32% Mortality 44%
Mortality: 13%
Conjoined twins
Ventral:
1) Omphalopagus
2) Thoracopagus
3) Cephalopagus
4) Caudal/ ischiopagus
Lateral:
1) Parapagus
Dorsal:
1)Craniopagus,
2)Pyopagus
Monozygotic / Uniovular / Identical Dizygotic / binovular / fraternal

1. 1/3 twins 1. 2/3 twins

2. 1. sperm and 1. ovum 2. 2 sperms and 2 ova

[Link] [Link] Diamniotic

twins

[Link] of placenta depends [Link] of chorionic tissue

on the time of splitting of between 2 amniotic sac
embryo
[Link] is dependent of
[Link] is independent race, age, parity, and
of race, age, parity ovulation inducing drugs
Superfecundation
Fertilization of two different ova released in the
same cycle
Superfetation
Fertilization of two ova released in different
cycles
Differences in zygocity

Monozygotic Dizygotic
1 ova + 1 sperm 2 ova + 2 sperm
Same sex Same or opposite sex
Identical features Fraternal resemblance
Single or double placenta Double or s/t fused
Same genetic features Different genetic features
DNA microprobe -same DNA microprobe - different
Diagnosis
HISTORY:
I. History of ovulation inducing drugs specially
gonadotrophins
II. Family history of twinning (maternal side).
SYMPTOMS:
i. Hyperemesis gravidarum
ii. Cardio-respiratory embarrassment - palpitation or shortness
of breath
iii. Tendency of swelling of the legs,
iv. Varicose veins
v. Hemorrhoids
vi. Excessive abdominal enlargement
vii. Excessive fetal movements.
GENERAL EXAMINATION:
I. Prevalence of anaemia is more than in singleton
pregnancy
II. Unusual weight gain, not explained by pre-eclampsia or
obesity
III. Evidence of preeclampsia(25%)is a common association.
ABDOMINAL EXAMINATION:
Inspection:
The elongated shape of a normal pregnant uterus is changed
to a more "barrel shape” and the abdomen is unduly
enlarged.
Palpation:
Fundal height more than the period of amenorrhoea
 girth more than normal
 Palpation of too many fetal parts
 Palpation of two fetal heads
 Palpation of three fetal poles
• Auscultation:
Two distinct fetal heart sounds
Zone of silence
10 beat difference
INVESTIGATIONS
Sonography: In multi fetal pregnancy it is done to
obtain the following information:
i. Suspecting twins – 2 sacs with fetal poles and
cardiac activity
ii. Confirmation of diagnosis
iii. Viability of fetuses, vanishing twin
iv. Chorionicity – 6 to 9 wks ( single or double
placenta, twin peak sign in d /d gestation or
Tsign in m/d )
v. Pregnancy dating,
Sonography ( ctd )

i. Fetal anomalies
ii. Fetal growth monitoring (at every 3-4 weeks
interval) for IUGR
iii. Presentation and lie of the fetuses
iv. Twin transfusion (Doppler studies)
v. Placental localization
vi. Amniotic fluid volume
D/D of increased fundal height
Full bladder
Wrong dates
Hydramnios
Macrosomia
Fibroid with preg
Ovarian tumor with preg
Adenexal mass with preg
Ascitis with preg
Molar pregnancy
Lie and Presentation
Longitudinal lie (90%)
1. both vertex (40%)
2. Vertex + breech (28%)
3. breech + vertex ( 9%)
4. both breech ( 6%)
Others
vertex + transverse
breech + transverse
both transverse
Maternal Complication
 Antenatal :
1. Hyperemesis gravidarum
2. ↑chances of abortion
3. hydramnios
4. PIH
5. Placenta previa, abruptio
6. Anemia
7. Exaggerated minor problems: pressure symptoms,
etc
Intrapartum :
1. Prolonged labor (uterine inertia)
2. Malpresentation
3. Cord prolapse
4. Abruptio placenta for 2 nd twin
5. PPH
Fetal complications
1. Preterm delivery
2. IUGR
3. Congenital Abnormalities
4. Cord abnormalities :
1. Single umbilical artery
2. Velamentous insertion
3. Cord entanglement
4. Cord prolapse
5. Monochorionic twins :
1. Discordant growth
2. Twin to twin syndrome
3. Single fetal Demise
Discordant growth - Difference of >25% in weight ,
>5% in HC, >20mm in AC, abnormal doppler waveforms
-
Causes – unequal placental mass, lower segment
implantation, genetic difference, TTTS, congenital
anomaly in one
TTTS -Twin to twin transfusion syndrome
TTTS -Twin to twin transfusion syndrome
- cause – AV communication in placenta – blood from one
twin goes to other – donor to recipient
- donor–
IUGR,oligohydramnios,anemia,hypotensive,hypovolemic
- recipient – overload,
hydramnios,polycythemia,hypertensive,hypervolemic, CHF,
IUD
Donor twin Recipient twin
Hypovolemic & oliguric/anuric Hypervolemic & polyuric

Result in stuck twin Can also develop

phenomenon where the twin HTN,hypertrophic
appears in a fixed position cardiomegaly,disseminated
against uterine wall intravascular coagulation,and
hyperbilirubinemia after birth
Ultrasound may fail to visualize
fetal bladder because of absent
urine

Both twin can develop hydrops foetalis Recipient becomes hydopic because
Donor can become hydropic because of hypervolemia
of anemia and high output heart
failure
TTTS Management

Antenatal diagnosis: ultrasound with doppler flow

study in the placental vascular bed.
Repeated amniocentesis to control polyhydramnios
in recipient twin.
– prevent preterm labour and placental abruption.
Selective reduction of one twin is done when survival
of both the fetuses is at risk.
Smaller twin generally have got better outcome.
Plethoric twin: risk of CCF and hydrops.
Perinatal mortality: 80%.
FETAL COMPLICATIONS (ctd)
TRAP
Twin reversed arterial perfusion
syndrome or Acardiac twin - absent heart in one fetus
with arterio-arterial communication in placenta
Cord entanglement and compression – more in
monoamniotic twins
Locked twins
Asphyxia – cord complication, abruption
Still birth – antepartum or intrapartum cause
Fetal acardius
Monoamniotic twins
high perinatal morbidity, mortality.
Causes : cord entanglement
congenital anomaly
preterm birth
twin to twin transfusion syndrome
 Management of multiple
pregnancy
Antenatal care :
 Extra attention & diet: at least 300 kcal more than in
normal pregnancy
 Routine iron and folic acid
 Detailed anomaly scan followed by serial growth scan
at 28, 32 and 36 week
 Hospitalization if suspected pretem
 Frequent and regular antenatal visit
 Corticosteroids -only in threatened preterm labour , same dose
RCOG recommended antenatal
care
Dichorionic Monochorionic
-Lead clinician with -Lead clinician with
multidisciplinary team multidisciplinary team
-US at 10-13wk : US at 10-13wk :
viability,chorionicity,NT:aneuploidy viability,chorionicity,NT:aneuploidy/T
TTS

-Structural anomaly scan at 20-22wk -US surveillance for TTTS and

discordant growth at 16wk and
then 2weekly
-Serial fetal growth scan -Structural anomaly scan 20-
eg:24,28,32 then 2-4weekly 22wk (including fetal ECHO)
-BP monitoring and urinalysis -fetal growth scan 2wkly interval
at 20,24,28 and then 2weekly until delivery
-Discussion of mother’s/family needs -BP monitoring and urinalysis
relating to twins at 20,24,28 then 2weekly
-34-36wk : discussion of mode of Discussion
Timing of delivery
 Uncomplicated dichorionic – by
38 week
 Uncomplicated monochorionic
– by 37
week
 TTTS – depend on current
situation
 MCMA – 32 week, by
LSCS
Mode of delivery
 Depend on presentation of 1st twin
 Both vertex / 1st twin
vertex – vaginal delivery
 Indication for Elective LSCS
-More than 2 fetuses
-1st twin
malpresentation, CPD
-Scarred uterus
-MCMA
-Conjoint twin
-IUGR in dichorionic
twin
-TTTS
 Emergency LSCS :
-Fetal distress
-cord prolapse in 1st baby
-Non progress of labor
-2 nd twin is transverse, version failed
after delivery of 1st twin
Management during labour 1st
stage
1. Determine the presentation of 1st twin
2. Maintain partogram
3. Keep NBM and establish IV line
4. Blood grouping and cross matched
5. Continous intrapartum twin CTG
monitoring
6. Analgesic
Management during labour 2nd
stage
1. Delivery of 1st twin
2. Clamp and cut the cord
3. Note lie of the 2 nd twin (delivered within 20 min)
4. Longitudinal lie (abdominally &
vaginally) : Start 2 units of pitocin IV drip
Cephalic  Fix the head into pelvisARM &
deliver the fetus
Breech  Assisted breech delivery,
Breech extraction
If 2 nd twin has transverse lie :
• Assistant performs ECV.
• Fix the head in lower pole of the uterus and
accoucher performs controlled ROM (rupture of
membrane)
• If this fails: do IPV (internal podalic version)
followed by breech extraction
• Or proceed with emergency LSCS
 MCQs
1. Splitting of single fertilized ovum between 8 to 12 days
results in
a) conjoined twins
b) monochorionic monoamniotic twin
c) dichorionic diamniotic twin
d) monochorionic diamniotic twin
 Splitting of single fertilized ovum between 8 to 12 days results
in
a) conjoined twins
b) monochorionic monoamniotic twin
c) dichorionic diamniotic twin
d) monochorionic diamniotic twin
2. Twin peak sign is a feature of
a) conjoined twins
b) monochorionic monoamniotic twins
c) dichorionic diamniotic twins
d) monochorionic diamniotic twins
Twin peak sign is a feature of
a) conjoined twins
b) monochorionic monoamniotic twins
c) dichorionic diamniotic twins
d) monochorionic diamniotic twins
 3. Twin pregnancy is complicated by all of the following
except
a) placenta previa
b) malpresentation
c) hydramnios
d) post term labour
 Twin pregnancy is complicated by all of the following
except
a) placenta previa
b) malpresentation
c) hydramnios
d) post term labour
4. Caesarean section is indicated in
a) monoamniotic twin
b) monochorionic twin
c) dichorionic twin
d) diamniotic twin
Caesarean section is indicated in
a) monoamniotic twin
b) monochorionic twin
c) dichorionic twin
d) diamniotic twin
5) 32year old G2P1 at 20 weeks pregnancy in USG shows
twin pregnancy, single placental mass with dividing
membrane having inverted T sign. The type of twinning is
a) monochorionic monoamnionic
b) monochorionic diamnionic
c) dichorionic monoamnionic
d) dichorionic diamnionic
 32year old G2P1 at 20 weeks pregnancy in USG shows twin
pregnancy, single placental mass with dividing membrane
having lambda sign. The type of twinning is
a) monochorionic monoamnionic
b) monochorionic diamnionic
c) dichorionic monoamnionic
d) dichorionic diamnionic
6) Monochorionic twin placenta has unidirectional deep
arteriovenous communication with lack of superficial vascular
anastomoses. The likely complication is
a) twin to twin transfusion syndrome
b) twin reversed arterial perfusion
c) acute intertwin transfusion
d) twin cord entanglement
 Monochorionic twin placenta has unidirectional deep arteriovenous
communication with lack of superficial vascular anastomoses. The
likely complication is
a) twin to twin transfusion syndrome
b) twin reversed arterial perfusion
c) acute intertwin transfusion
d) twin cord entanglement
7) Most common variety of conjoined twins is
a) craniopagus
b) thoracopagus
c) omphalopagus
d) pyopagus
7) Most common variety of conjoined twins is
a) craniopagus
b) thoracopagus
c) omphalopagus
d) pyopagus
Thank You